Images in Emergency Medicine
Ocular Ultrasound Identifies Early Orbital Cellulitis Tarina L. Kang, MD Dina Seif, MD Mikiaela Chilstrom, MD Tom Mailhot, MD
University of Southern California, Department of Emergency Medicine, Los Angeles, California
Supervising Section Editor: Sean O. Henderson, MD Submission history: Submitted March 28, 2014; Accepted April 14, 2014 Electronically published May 27, 2014 Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.2014.4.22007
[West J Emerg Med. 2014;15(4):394.] A 36 year-old man with a history of a complicated oral surgery from a complex mandibular fracture months prior presented with traumatic right eye swelling, tearing, and redness. The patient was afebrile (36.7º C) and normotensive (121/79). Physical examination revealed upper and lower lid swelling and erythema without crepitance or proptosis, accompanied by conjunctival injection and copious tearing. His pupillary exam and intraocular pressures were normal. He had painless and unlimited extra-ocular movements. His visual acuity was 20/30 oculus dexter, 20/20 with pinhole; 20/40 oculus sinister, 20/40 with pinhole. A bedside ocular ultrasound using a Sonosite MTurbo® 7.5 MHz linear high frequency probe was performed showing edema along the anterior aspect of the orbit with nonspecific thickening of the orbital wall (Video). Based on these findings, an orbital computed tomography (CT) with contrast was performed, confirming the diagnosis of orbital cellulitis. The patient was admitted for intravenous antibiotics (vancomycin and ceftriaxone) and ophthalmology consultation. While there are numerous studies supporting the use of orbital ultrasound to diagnose ocular trauma, the presence of intraocular foreign bodies, and other ocular abnormalities, there is limited evidence to suggest orbital ultrasound may have a role in diagnosing orbital cellulitis.1-7 It is not likely that ocular ultrasound will negate the need for advanced imaging with CT and magnetic resonance imaging in patients with symptoms highly suggestive of orbital cellulitis (i.e., ophthalmoplegia, proptosis, and impaired vision.) However, ocular ultrasound may have a role in risk stratification for patients with more nonspecific symptoms, such as ocular pain, eyelid swelling, and erythema. Future observational studies are needed to better evaluate if orbital ultrasound has a role in identifying patients without obvious clinical features of orbital cellulitis who may benefit from advanced imaging. Western Journal of Emergency Medicine
Video. Edema along the anteriorlateral aspect of the orbit with nonspecific thickening of the orbital wall (white arrows). Address for Correspondence: Tarina L. Kang, MD. LAC+USC Medical Center, Department of Emergency Medicine, 1200 North State Street Room 1011, Los Angeles, CA 90033. Email: tarina.lee. [email protected] Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. REFERENCES
394
1. Shinar Z, Chan L, Orlinsky M. Use of ocular ultrasound for the evaluation of retinal detachment. J Emerg Med 2011;40(1):53-7. 2. Yoonessi R, Hussain A, Jang TB. Bedside ocular ultrasound for the detection of retinal detachment in the emergency department. Acad Emerg Med 2010;17(9):913-7. 3. Hande P, Talwar I. Multimodality imaging of the orbit. Indian J Radiol Imaging 2012;22(3):227-239. 4. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med 2002;9(8):791-9. 5. McNicholas MM, Brophy DP, Power WJ, et al. Ocular trauma: evaluation with US. Radiology 1995;195(2):423-7. 6. Mair MH, Geley T, Judmaier W, et al. Using orbital sonography to diagnose and monitor treatment of acute swelling of the eyelids in pediatric patients. AJR 2002; 179:1529-1534. 7. Kaplan DM, Briscoe D, Gatot A, et al. The use of standardized orbital ultrasound in the diagnosis of sinus induced infections of the orbit in children: a preliminary report. Int J Pediatr Otorhinolaryngol 1999;48:155-162.
Volume XV, NO. 4 : July 2014
Ocular Ultrasound Identifies Early Orbital Cellulitis Tarina L. Kang, MD Dina Seif, MD Mikiaela Chilstrom, MD Tom Mailhot, MD
University of Southern California, Department of Emergency Medicine, Los Angeles, California
Supervising Section Editor: Sean O. Henderson, MD Submission history: Submitted March 28, 2014; Accepted April 14, 2014 Electronically published May 27, 2014 Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.2014.4.22007
[West J Emerg Med. 2014;15(4):394.] A 36 year-old man with a history of a complicated oral surgery from a complex mandibular fracture months prior presented with traumatic right eye swelling, tearing, and redness. The patient was afebrile (36.7º C) and normotensive (121/79). Physical examination revealed upper and lower lid swelling and erythema without crepitance or proptosis, accompanied by conjunctival injection and copious tearing. His pupillary exam and intraocular pressures were normal. He had painless and unlimited extra-ocular movements. His visual acuity was 20/30 oculus dexter, 20/20 with pinhole; 20/40 oculus sinister, 20/40 with pinhole. A bedside ocular ultrasound using a Sonosite MTurbo® 7.5 MHz linear high frequency probe was performed showing edema along the anterior aspect of the orbit with nonspecific thickening of the orbital wall (Video). Based on these findings, an orbital computed tomography (CT) with contrast was performed, confirming the diagnosis of orbital cellulitis. The patient was admitted for intravenous antibiotics (vancomycin and ceftriaxone) and ophthalmology consultation. While there are numerous studies supporting the use of orbital ultrasound to diagnose ocular trauma, the presence of intraocular foreign bodies, and other ocular abnormalities, there is limited evidence to suggest orbital ultrasound may have a role in diagnosing orbital cellulitis.1-7 It is not likely that ocular ultrasound will negate the need for advanced imaging with CT and magnetic resonance imaging in patients with symptoms highly suggestive of orbital cellulitis (i.e., ophthalmoplegia, proptosis, and impaired vision.) However, ocular ultrasound may have a role in risk stratification for patients with more nonspecific symptoms, such as ocular pain, eyelid swelling, and erythema. Future observational studies are needed to better evaluate if orbital ultrasound has a role in identifying patients without obvious clinical features of orbital cellulitis who may benefit from advanced imaging. Western Journal of Emergency Medicine
Video. Edema along the anteriorlateral aspect of the orbit with nonspecific thickening of the orbital wall (white arrows). Address for Correspondence: Tarina L. Kang, MD. LAC+USC Medical Center, Department of Emergency Medicine, 1200 North State Street Room 1011, Los Angeles, CA 90033. Email: tarina.lee. [email protected] Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none. REFERENCES
394
1. Shinar Z, Chan L, Orlinsky M. Use of ocular ultrasound for the evaluation of retinal detachment. J Emerg Med 2011;40(1):53-7. 2. Yoonessi R, Hussain A, Jang TB. Bedside ocular ultrasound for the detection of retinal detachment in the emergency department. Acad Emerg Med 2010;17(9):913-7. 3. Hande P, Talwar I. Multimodality imaging of the orbit. Indian J Radiol Imaging 2012;22(3):227-239. 4. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med 2002;9(8):791-9. 5. McNicholas MM, Brophy DP, Power WJ, et al. Ocular trauma: evaluation with US. Radiology 1995;195(2):423-7. 6. Mair MH, Geley T, Judmaier W, et al. Using orbital sonography to diagnose and monitor treatment of acute swelling of the eyelids in pediatric patients. AJR 2002; 179:1529-1534. 7. Kaplan DM, Briscoe D, Gatot A, et al. The use of standardized orbital ultrasound in the diagnosis of sinus induced infections of the orbit in children: a preliminary report. Int J Pediatr Otorhinolaryngol 1999;48:155-162.
Volume XV, NO. 4 : July 2014
